Form 4 - Certification.pdf

FORM 4 –

CERTIFICATION

I certify that I am the authorized representative of _________________________ (“Company”), and that the following statements are true to the best of my knowledge, information, and belief:

I affirm that neither Company, nor any director, officer, controlling shareholder, partner, principal or any other person substantially involved in the contracting activities of the Company has in the past five (5) years:

(a) Been convicted under state or federal statutes of a criminal offense incident to obtaining or attempting to obtain or performing a public or private contract;

(b) Been convicted under state or federal statutes of fraud, embezzlement, theft, forgery, falsification or destruction of records, or receiving stolen property;

(c) Been found civilly liable under state or federal antitrust or other statutes for acts or omissions in connection with the submission of bids, proposals or qualifications for, or performance of, a public or private contract;

(d) Been criminally convicted of any violation of a state or federal antitrust statute;

(e) Been convicted under the provisions of Title 18 of the United States Code for violation of the Racketeer Influenced and Corrupt Organizations Act, 18 USC §1961 et seq., or the Mail Fraud Act, 18 USC §1341 et seq., for acts arising out of the submission of bids, qualifications, or proposals for a public or private contract;

(f) Been criminally convicted of conspiracy to commit any act or omission that would constitute grounds for conviction or liability under any statute described in paragraphs (a), (b), (d), or (e) above; or

(g) Admitted in writing or under oath, during the course of an official investigation or other proceeding, acts or omissions that would constitute grounds for conviction under any statute described above.

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